Due to a variety of impingements on their clinical decision making and overall practice autonomy, many physicians are expressing feelings of professional burnout and are disengaging from patient care roles as a result. In this paper the authors trace the causes of physician burnout and dissatisfaction and the ways in which physicians are seeking alternative practice styles. They then outline steps medical practices can take to keep physicians engaged in patient care and productive in their practices.
In January of 2019, the Harvard T.H. Chan School of Public Health, the Harvard Global Health Institute, the Massachusetts Medical Society and the Massachusetts Health and Hospital Association released a report titled “A Crisis in Health Care: A Call to Action on Physician Burnout.” The study’s authors labelled physician burnout as a public health crisis that “urgently demands action” from the healthcare industry.
The report was followed by a June 2019 paper in The Annals of Internal Medicine pegging the national annual cost of physician burnout at $4.6 billion, based on the expense of replacing burned out physicians who have left their jobs and on the cost of burned out physicians lowering their work hours (Estimating the Attributable Cost of Physician Burnout in the U.S. Annals of Internal Medicine. June 4, 2019)
The level of physician burnout and some of its causes are captured in a national survey of physicians that Merritt Hawkins conducts biennially on behalf of The Physicians Foundation, a not-for-profit grant making organization dedicated to advancing the work of practicing physicians. The 2018 Survey of America’s Physicians features responses from close to 9,000 doctors and has a margin of error of +/- 1.057%.
Following is one of 2,472 written comments physicians included in the survey when asked to express their opinions on the state of medical practice in America today:
“I am retiring completely in one month. Mostly because of burnout. I find it stressful to adequately treat my patients and keep up with all the insurance red tape and government regulations.”
This comment gets to the heart of the thousands of data points included in the survey, which provides a snapshot of the career plans, career metrics and perspectives of today’s doctors.
Consider three questions posed by the survey and the responses they generated:
Which best describes your professional morale and your feelings about the current state of the medical profession?
Very or somewhat positive: 44.7% Very or somewhat negative: 55.3%
Would you recommend medicine as a career to your children or other young people?
Yes: 51.3% No: 48.7%
How often do you have feelings of burnout in your career?
Sometimes/often/always: 77.8% Never/rarely: 22.3%
Source: A Survey of America’s Physicians: Practice Patterns and Perspectives. The Physicians Foundation/Merritt Hawkins. September, 2018.
To these generally negative responses could be added similar responses from a variety of other physician surveys, as well as the tens of thousands of conversations Merritt Hawkins’ consultants have with physicians every year. The conclusion is inescapable. Physicians today are feeling frustrated and powerless - and many are looking for a way out. The responses to another question asked in the survey revealing (see below):
In the next one to three years, do you plan to: (check all that apply)
Continue as I am 54.2%
Cut back on hours 22.3%
Seek a non-clinical job 12.4%
Work locum tenens 8.4%
Seek employment with a hospital 4.3%
Work part-time 8.5%
Switch to a concierge practice 4.5%
Merge with another physician group 2.8%
Sell my practice to a hospital 2.2%
Source: A Survey of America’s Physicians: Practice Patterns and Perspectives. The Physicians Foundation/Merritt Hawkins. September, 2018.
Though 54.2% of physicians said they plan to continue practicing as they are, a sizeable minority (45.8%) said they will take one of a variety of steps that will either remove them from patient care roles altogether (such as retiring or finding a non-clinical job) or reduce the number of patients they see (such as working part-time, switching to concierge practice, or working locums). Those who continue in patient care roles may seek a more favorable environment in another location. The annual physician relocation/turnover rate now stands at about 12%, according to database company SK&A.
Physician disengagement from medicine is taking place at a particularly inopportune time, as physicians are in increasingly short supply. The Association of American Medical Colleges (AAMC) indicates there now is a shortage of approximately 22,000 physicians nationwide which could increase to as many as 122,000 physicians by 2032 (The Complexities of Physician Supply and Demand Projections From 2017 to 2032. Association of American Medical Colleges. April, 2019). Already, it can be difficult for patients to schedule physician appointments, a trend underlined by Merritt Hawkins’ 2017 Survey of Physician Appointment Wait Times and Medicaid and Medicare Acceptance Rates. The survey indicates that even in large metro areas with a high number of physicians per capita, patients can wait for weeks to schedule a physician appointment (see chart below).
Average Time to Schedule a New-Patient Appointment/Family Practice
Boston 109 days
Los Angeles 42 days
Portland 39 days
Miami 28 days
Atlanta 27 days
Source: Merritt Hawkins 2017 Survey of Physician Appointment Wait Times and Medicaid and Medicare Acceptance Rates.
The average wait time to see a family physician in smaller metro areas of approximately 100,000 people is considerably longer at 54 days, according to the survey.
A Day in the Life
The causes for physician dissatisfaction and disengagement are varied but can be distilled to one word: “control,” or rather, the lack of it. After four years of college, four years of medical school, and three to seven or more years of training, many physicians go through their day feeling powerless, despite their unique, specialized knowledge. Physicians look out at today’s medical practice environment and perceive that third parties:
*Control their fees
*Dictate patient care decisions/options
*Impose EHR use
*Necessitate defensive medicine/over-utilization
*Impose impractical diagnostic codes
*Grade/compensate on subjective criteria
They also perceive that no organization is protecting their interests, as American Medical Association (AMA) membership has fallen to less than 20% of all physicians. As a result, many physicians are at the breaking point. Close to 400 physicians commit suicide each year, at a rate of 28-40 per 100,000, which is twice the national rate of 12.3% per 100,000, according to a 2018 study presented before the American Psychiatric Association. This is the highest suicide rate of any profession. In response, physicians are working fewer hours, seeing fewer patients, and seeking avenues out of traditional patient care roles, The Physicians Foundation survey indicates.
Keeping physicians engaged in their profession is a critical challenge in this turbulent era of health system transformation, necessary for the success of individual medical practices and also vital to maintaining patient access to medical services. Some of the issues eroding physician engagement are societal in nature and are beyond the control of any given practice. However, there are steps practices can take that can be taken to promote physician satisfaction and engagement and reduce burnout, including:
Have a Vision
How healthcare is delivered is rapidly changing. Larger, integrated delivery models employing team-based care within capitated payment structures that reward value are proliferating. There is also an industry-wide movement toward outpatient care that offers patients convenience and quick access to healthcare professionals. One practice structure may not fit all, but change will continue and that breeds uncertainty.
To stay engaged, physicians need a vision of where the practice is going. Will there be growth through mergers, consolidation, or affiliations? To what extent will team-based care, telemedicine, and emerging IT systems be embraced? At what point on the spectrum between independent, fee-for-service, private practice medicine, and the integrated/employed, value-based model will the practice lie?
Not all physicians may buy-into the vision, but certainty about the direction (and, it is to be hoped, eventual consensus) is preferable to indecision and confusion.
Enhance the “Workshop”
Though you may not be able to control the weather outside where you live, you can control the environment inside your home. Similarly, an individual practice may not be able to control federal policies and other macro trends shaping the medical practice environment, but it can control the quality of its practice from the physicians’ perspective. Ensuring the most open, efficient, fair, and remunerative practice environment possible is critical to maintaining physician engagement. A desirable “workshop” may include the following:
*Physician communication (formal and informal) to promote physician input, governance and decision making
*Appropriate nurse/advanced practitioner/administrative staffing
*Appropriate EHR selection/training/support
*Clear, competitive reimbursement and bonus formulas (discussed below)
*Flexible schedule, including part-time
*Timely test turnaround
*Timely hospital admissions
*Timely access to patient data
*Timely access to the OR
*Pay for ED call
*Hospitalist program allowing an outpatient only practice
*Gain sharing/joint ventures
*Enhanced ER triage
*Convenient, available parking
Since the practice’s affiliated hospital also may be part of the physician’s workshop, it is important to cultivate positive relations and to influence physician-friendly hospital practices. A positive practice environment can increase physician retention and strength the practice’s recruiting posture.
Offer Clear, Competitive Compensation Formulas
In today’s evolving healthcare market, physician compensation formulas often seem to be obsolete the moment they are adopted. Nevertheless, compensation models tend to have similar characteristics. Of the 3,131 physician search assignments Merritt Hawkins conducted from April 1, 2018 to March 31, 2019, 70% featured a salary with a production bonus, 22% featured a straight salary, 2% featured a private practice income guarantee, and 6% featured some other form of compensation.
The variation (and contention) over compensation usually involves the metrics of the production bonus. Of those searches Merritt Hawkins represented offering a salary and production bonus, the bonus was based on the following metrics:
On Which Metrics Was the Bonus Based? (check all the apply)
Net Collections 18%
Gross Billings 3%
Patient Encounters 9%
Source: Merritt Hawkins 2019 Review of Physician and Advanced Practitioner Recruiting Incentives
As these numbers indicate, 56% of physician production bonus formulas featured “quality” (defined as patient satisfaction, adherence to protocols, reduction of errors, appropriate coding, etc.) as a metric. This is the highest number Merritt Hawkins has recorded, but still represents a bare majority.
Despite the broad movement from volume to value, in real world physician compensation scenarios, volume-based metrics such as RVUs still predominate, in part because they are more objective and more easily understood than quality/value-based metrics. Clarity is the key characteristic of physician friendly compensation formulas, whether based on volume or value, and such formulas are central to maintaining physician engagement. They should be easily understood and fair, accounting for differences in the patient mix of individual physicians. Compensation also should be competitive, which can be determined through by referencing a variety of physician compensation surveys.
Consider Team-Based Care
Some physicians remain hesitant about the use of advanced practitioners such physician assistants (PAs) and nurse practitioners (NPs). However, incorporating these and other clinicians into the team-based model frees physicians to practice to the top of their training and to focus on the most challenging (and, often, the most stimulating) aspects of their specialty while potentially expanding the practice and increasing revenues.
Seek a Partner
There are various levels of partnership that medical practices can form with hospitals or large groups to achieve economies of scale, compete for population health contracts, and, in general, weather the storms of change. The “physician enterprise model” (also known as “practice leasing”) is one that offers the management resources of a hospital but allows physicians to preserve clinical autonomy. Whether the relationship features employment of the physician or a less formal association, a partner may be needed to offer physicians the stability and resources they require to stay in the game.
Recruit to Retain
The physician recruiting process can be a foundation on which positive physician relations rests or it can undermine the relationship physicians have with their groups. Problems created or compounded by physician recruiting practices arise in two areas. The first is an insufficiently detailed or accurate practice opportunity presentation. If expectations regarding required work hours, patients seen per day, group governance, quality metrics, compensation and related issues are not clearly communicated to candidates on the front end of the recruiting process, misunderstandings that lead to physician disengagement, burnout and turnover can result on the back end.
It is important to delineate in writing exactly what is expected of the physician, and make sure to accurately project the financial potential of the practice so that expectations are realistic and achievable. The majority of these details should be communicated during the candidate screening process, before the physicians arrives for the on-site interview.
There are emerging innovations in both technology and practice structures that can save physicians time and keep them engaged. These include telemedicine and home health devices that allow physicians to engage patients with mutual convenience, online patient scheduling, and mobile electronic health records (EHR). Innovations such as shared medical appointments allow physicians to see multiple patients with similar needs, such as pre-natal care, at one time, freeing up schedules and allowing for more flexibility. Scribes can relieve physicians of EHR data entry and practices can eliminate many of the reimbursement and clinical autonomy issues that physicians deplore by adopting the concierge model.
Whatever steps are taken, it is important for practice managers and any other professionals who interact with physicians to understand their challenges, frustrations and their state of mind. Physicians are still devoted to their patients and enjoy the clinical aspects of what they do. They are looking for allies and will reward those who let them do want they do best with commitment, engagement and productivity.
Kurt Mosley is Vice President of Strategic Alliances with Merritt Hawkins (www.merritthawkins.com) the nation’s leading physician search firm and a company of AMN Healthcare (NYSE: AHS). Phillip Miller is Vice President of Communications with Merritt Hawkins. Email firstname.lastname@example.org and email@example.com.
This article first appeared in the Journal of Medical Practice Management, 2018